Report from Kuwait:
Gulf War Illnesses Strike Civilians and Veterans of the 1991 Gulf War
By Prof. Garth L. Nicolson
The Institute for Molecular Medicine
15162 Triton Lane, Huntington Beach, CA 92649-1401
As we came up over the ridge north of the town of Al-Jahra near the western end of the Bay of Kuwait on the highway from Kuwait City to Basra, Iraq little could be seen of the carnage that took place in the early morning hours of February 26, 1991. The war with the U.S.-led coalition forces was not going well for the Iraqi Army, and U.S. Marine and Arab coalition units were on the southern outskirts of Kuwait City. Iraqi forces remaining in Kuwait City were hastily attempting to withdraw north from Kuwait in a column of over a thousand vehicles, from Iraqi tanks to stolen civilian buses and cars, while U.S. Navy and Air Force ground attack aircraft plummeted them with cluster bombs and depleted uranium (DU) munitions. At the time, this was dubbed "The Highway of Death" by the press. Since the highway north must go over the ridge where we were now standing, it was a perfect trap for Suddam s forces. Unfortunately, many Kuwaiti civilians who were hostages probably also died that day on the Highway of Death. Our host, Professor Jassim Mohammad Al-Hassan of the Faculty of Science at Kuwait University where I spent the spring as a Distinguished Visiting Professor and lecturer, quietly told us that Kuwaiti Graves Units buried over 450,000 Iraqis in the deserts of Kuwait. As we approached one area where the sand appeared to have been piled into defensive berms, Professor Jassim related his wartime stories as a resistance fighter and then officer in charge of a burial detail along the Highway of Death. "We buried thousands of Iraqis here" as he pointed to an area just off the highway. Later as we came upon a fenced area, I asked Professor Jassim what was buried behind the fence. As it turns out, this was the new home of the radioactive Iraqi equipment that was hit with radioactive DU munitions. After the war, the Kuwaiti Ministry of Health ordered that all contaminated vehicles be buried in the sand to protect Kuwaitis from the health effects of DU.
Depleted Uranium (DU) and the Gulf War
Although DU contamination is only one of the several health problems that many Kuwaitis and veterans of Desert Storm face, it s a problem that won t go away quickly. Radioactive DU has a half-life of 4.4 billion years. DU is a by-product of uranium processing where the more enriched uranium (mostly U-235) is concentrated for use as nuclear reactor fuel . The DU that is left over, hundreds of thousands of pounds of it or more, have been building up for decades around government uranium processing plants. Since it has such high density, someone determined that DU is very useful in a tungsten mixture for the construction of armor-penetrating munitions. Unfortunately, DU still contains about 30% of the radioactivity found in enriched uranium, and it is extremely dangerous to animals and humans . When super-high velocity DU munitions hit their hardened targets, the kinetic energy is so high that the DU actually vaporizes and burns to form uranium oxide, a fine dust of DU oxide particles that slowly settles in the area and onto the sand where it can eventually contaminate ground water for hundreds of thousands of years. U. S. and British forces expended between 400-800 tons of DU during the Gulf War, and very little of extremely toxic material has been contained.
Most of the recent health problems with DU presumably started with inhalation of the fine DU oxide particles and their lodgment at sites deep in the lungs. The irradiation of lung tissues surrounding DU oxide particles can result in a slow process of immune suppression and pneumonitis. Some of this DU oxide will eventually enter the body as uranium cations, and unfortunately, it has a tendency to concentrate in the bones, affecting bone marrow and blood cell production. It has been only recently that our military has been informing soldiers of the dangers of DU, but this may come too late for veterans of the Gulf War who inspected destroyed armored vehicles and bunkers or who were hit with friendly fire DU munitions. And DU is only one of the problems facing veterans of Desert Storm and civilians of Kuwait and Southern Iraq.
Chemical Contamination of Kuwait in 1991
During the spring of 1991 there was not much sunlight in Kuwait. Hundreds of oil well fires were still spewing unknown amounts of smoke and pollutants into the air, so much so that there was not much light reaching the ground, even at midday. Night or day during this period vehicles were required to use their headlights. This is the aftermath of Saddam s decision to sabotage the producing oil wells in Kuwait. Over 1,150 wells out of 1,313 operating wells were sabotaged in Kuwait by the Iraqi Army . Not all of the wells caught fire, and many just released crude oil as gushers that contaminated the environment and formed many artificial oil lakes. The estimated loss was over 2 billion barrels of crude oil, of which several hundred million barrels formed into about 70 major oil lakes that proved to be disastrous to migratory birds . Most of these lakes have now been drained, but the oil residues remain. Also, the Iraqi Army dug hundreds of miles of oil trenches that were to be ignited to form defensive lines of fire. Many of the sabotaged wells were destroyed to release oil into collecting lakes which then fed into the defensive trenches. It has been only recently that the Kuwait Institute of Scientific Research (KISR) has developed procedures to reclaim these oil lakes and trenches and turn them back to their prewar conditions. When we examined the KISR experimental reclamation project, it was clear that it will take many years if not decades to return the Kuwait environment to its prewar state. Although a survey of the environmental contamination has been conducted, a health survey of the population of Kuwait has not yet been undertaken.
Illnesses in the Civilian Population of Kuwait After the Gulf War
The polluted environment in Kuwait is not the only example that remains of the 1991 Gulf War. After discussions with Kuwaiti physicians who run the many clinics in Kuwait City and with the former Minister of Health Dr. Abdul Rahman Al-Awadi, it is clear that many Kuwaiti civilians slowly became sick with Gulf War Illnesses. Our estimates of illness of approximately 15% of the civilian population have been confirmed by an independent survey conducted by Dr. Charles T. Hinshaw, past-president of the American Academy of Environmental Medicine. Similar to the over 100,000 U. S. veterans with Gulf War Illnesses, Kuwaiti civilians present with overlapping, complex, multi-organ chronic signs and symptoms . These include chronic fatigue, headaches, memory loss, muscle pain, nausea, gastrointestinal problems, joint pain, lymph node pain, memory loss, and other signs and symptoms. Often included in this complex clinical picture are increased sensitivities to various environmental agents and enhanced allergic responses. Are these civilians presenting with the same complex signs and symptoms found in our veterans? It appears so, but these illnesses are complex and are likely due to a variety of toxic environmental exposures and possibly opportunistic infections as well .
The most common diagnosis of Kuwaiti civilians who have been ill since the Gulf War is Chronic Fatigue Syndrome (CFS). Patients with chronic illnesses, such as CFS, Fibromyalgia Syndrome (FMS), Gulf War Illnesses (GWI) and some Rheumatoid Arthritis (RA) usually have overlapping signs and symptoms, which led us to propose that these are somewhat similar clinical conditions that may have many different causes . Although these syndromes have been known for several years, most patients with CFS, FMS, GWI or RA have had few options when it came to effective treatments. This may be due to the imprecise nature of their diagnoses, which are often based on clinical observations rather than laboratory tests that could identify underlying causes for their illnesses.
Similarities Between CFS, FMS, GWI and Other Chronic Illnesses
We have found that the signs and symptoms of CFS and FMS overlap with those found in GWI, suggesting that these are not separate syndromes, they are all CFS-like disorders . The main distinguishing characteristic of FMS is severe muscle pain and soreness, and this can also be seen in many FMS, RA and GWI patients. In some cases, these illnesses have apparently spread to immediate family members. In the case of GWI, over 100,000 veterans of the Persian Gulf War in 1991 have been found to have this disorder, not including immediate family members. According to one government study, GWI has spread to family members , and it is likely that it has also spread in the workplace. Although this U.S. Senate committee study was incomplete, investigators found after surveying approximately 1,200 GWI families that 77% of spouses and a majority of children born after the war had the signs and symptoms of GWI . Notwithstanding the official position of Department of Defense (DoD) remains that family members have not contracted GWI, this U. S. Senate study indicates that at least a subset of GWI patients have a transmittable illnesses . Similarly, some CFS patients have complained that their immediate family members now show some of the signs and symptoms of CFS. In Kuwait this is also apparent, but careful studies of the illnesses in the Kuwaiti population are lacking.
Does Stress affect CFS, FMS, GWI or RA?
One of the most distressing aspect of the aftermath of the Gulf War was the determination of the DoD that most GWI cases can be attributed to stress . Can stress affect health and chronic illnesses? Most researchers would agree that it can, especially by affecting the immune system, but the notion that stress is the cause of chronic illnesses like CFS, FMS, GWI and RA is, in our opinion, far fetched . Patients with CFS, FMS, GWI and sometimes RA often have cognitive problems, such as short-term memory loss, problems concentrating and other psychological problems. In fact, psychologists or psychiatrists who examine CFS, FMS or GWI patients often find psychological or psychiatric problems in these patients and decide in the absence of contrary laboratory findings that these conditions are somatoform disorders. That means that these practitioners decide that these illnesses are caused solely by psychological or psychiatric problems, not medical problems that can be treated with medicines or treatments that are not specific for the Central Nervous System. Stress is often mentioned as an important factor or the important factor in these disorders. In particular, GWI patients are often diagnosed with Post Traumatic Stress Disorder (PTSD) in veterans and military hospitals . The evidence that physicians have offered as proof that stress or PTSD is the source of most GWI sickness is the assumption that most veterans must have suffered from stress by virtue of the stressful environment in which they found themselves during the Gulf War . In fact, U. S. veterans themselves do not feel that stress-related diagnoses are an accurate portrayal of their illnesses. Most testimony to the U. S. House of Representatives Committee on Government Reform and Oversight studying the origins of GWI refutes the notion that stress is the major cause of GWI . The General Accounting Office (GAO), the investigation arm of the U.S. Congress, after studying government and civilian data on the subject concluded that while stress can induce some physical illness, the statement that stress is the causes of GWI has not been established . Similarly, evidence is lacking that stress can cause CFS, FMS or RA.
Similar to environmental toxic exposures, such as chemicals and radiological agents, the main effect of stress appears to be that it can exacerbate chronic illnesses and suppress immune systems. But most military personnel that we interviewed, including highly disciplined U. S. Special Forces and Navy SEALS, indicated that the Gulf War was not a particularly stressful war, and they strongly disagreed that stress was the origin of their illnesses . However, in the absence of physical or laboratory tests that can identify possible origins of CFS, FMS or GWI, many physicians accept that stress is the cause of these chronic illnesses. It was only recently that other causes have been seriously considered, including toxic chemical and biological exposures.
Chronic Illnesses and Toxic Exposures: A Multi-Hit Process
When trying to determine why chronic illness patients are sick, we feel it is imperative to have some idea of the types of toxic exposures that may have occurred. In the case of GWI and civilian illnesses in the Gulf Region, toxic exposures occurred in 1991 during and after the Gulf War, and this provides us with a baseline for study. As a control, we know that deployed military personnel were not sick before they were deployed, and this serves as a baseline to compare what may have happened in the Gulf Region in 1991. For example, all British, Canadian and U. S. military personnel had to pass a medical exam before deployment, and thus the chance that previously sick soldiers were deployed is very unlikely. We have assumed that chemical and biological and in some cases radiological exposures occurred during the Gulf War, and many civilian patients in Kuwait (or elsewhere) may have also been exposed to chemical and biological substances that could be an underlying cause of their illnesses .
We have proposed that the complex signs and symptoms found in some CFS, FMS, GWI and RA patients maybe due to system-wide or systemic chronic infections following chemical or radiological insults that suppress the immune system. Thus this is a multistep process that may involve multiple toxic exposures (Figure 1). Chronic infections that are usually held in check by the immune system can take hold if they can avoid the host s immune surveillance and penetrate various tissues and organs, including the Central and Peripheral Nervous Systems . When such infections occur, they can cause the complex signs and symptoms seen in CSF, FMS and GWI, including immune dysfunction . Changes in environmental responses as well as increased titers to various endogenous viruses that are commonly found to be expressed in these patients have been seen in CFS, FMS and GWI. If infectious agents are involved, few can produce the complex chronic signs and symptoms found in CFS, FMS and GWI and some RA patients. One type of airborne infection that has received renewed interest of late as an important element in these disorders is represented by the class Mollicutes . These microorganisms, principally mycoplasmas and other rather primitive bacteria, although not well known agents in causing disease, are now considered important emerging pathogens in causing chronic diseases and may also be important cofactors in some illnesses, including AIDS and other Immunodeficiency Disorders, skin diseases and some autoimmune diseases .
As chronic illnesses such as GWI (and in some cases CFS, FMS and RA) progress, there are a number of accompanying clinical problems, particularly increases in autoimmune problems. These include in some patients acquiring some of the signs and symptoms of Multiple Sclerosis (MS), Amyotrophic Lateral Sclerosis (ALS or Lew Gehrig s Disease), Lupus, Graves Disease, Arthritis and other complex autoimmune diseases. Such usually rare autoimmune responses are consistent with certain chronic infections, such as mycoplasmal infections that penetrate into nerve cells, synovial cells and other cell types. It is proposed that these autoimmune signs and symptoms are caused when intracellular pathogens, such as mycoplasmas and other bacteria, escape from cellular compartments. Some microorganisms like mycoplasmas can incorporate into their own structures pieces of host cell membranes that contain important host membrane antigens that can trigger autoimmune responses. Thus patients with such infections may be responding to microorganism antigens as well as their own membrane antigens, producing unusual autoimmune signs and symptoms.
Microorganisms Cause Morbidity in Many CFS, FMS, GWI and RA Patients
Most microorganisms like mycoplasmas are not considered as important human pathogens when they are found at superficial sites, such as the oral cavity, but some species, such as M. fermentans, M. penetrans, M. pneumoniae, M. genitalium, M. pirum and M. hominis, among others, have the capacity to penetrate into blood and colonize various tissues and have been closely associated with various human diseases . Do these agents cause CFS, FMS, GWI or RA? Not necessarily on their own, but microorganisms like Mycoplasma, Chlamydia, Brucella, Coxiella and other bacteria and some viruses appear to be important in causing patient morbidity, or exacerbating the major signs and symptoms seen in patients with chronic illnesses. These patients may have had previous chemical or other toxic exposures that resulted in immune suppression. If such microorganisms are associated with chronic illnesses, is there any evidence for microorganism infections in CFS, FMS, GWI or RA patients? The answer is YES. In about 60% of CFS/ME, 70% of FMS, 50% of GWI and 55% of RA patients examined we and others, principally Dr. Daryl See of the University of California College of Medicine, Irvine, and Eli Mortechai of Medical Diagnostics of New Jersey, are finding strong evidence for mycoplasmal blood infections that can explain much if not most of the chronic signs and symptoms found in these patients. In our studies on GWI, a CFS/FMS-like illness , we have found mycoplasmal infections in the blood of about one-half of over 200 patients, and these patients were found to have principally one infectious species of mycoplasma, M. fermentans [12, 13]. However, in about 60% of the 150 civilians with CFS/ME, FMS or RA that we have examined we are finding a variety of pathogenic mycoplasma species, such as M. fermentans, M. penetrans, M. pneumoniae, M. genitalium, M. pirum and M. hominis, in the white blood cell fractions of blood samples . The tests that we use to identify mycoplasmal infections, polymerase chain reaction and nucleoprotein gene tracking, are very sensitive and highly specific for mycoplasmas. These tests are a dramatic improvement over the relatively insensitive serum antibody tests that are currently used to assay for systemic mycoplasmal infections. We have recently received a DoD contract to train scientists and physicians to perform these tests, including the training of staff from the Armed Forces Institute of Pathology and Walter Reed Army Medical Center. Mycoplasmas aren t the only microorganisms found in GWI patients. We have preliminary evidence for Brucella, Coxiella and other chronic infections in GWI patients, and it is likely that at least some of these infectious agents will also be found in civilians with CFS, FMS or RA.
Antibiotic/Vitamin/Nutritional Treatments for Chronic Illnesses
When microorganism infections are identified in the white blood cell fractions of subsets of patients with CFS, FMS, GWI or RA, these patients can be treated as medical not psychological or psychiatric patients. If such infections are important in these disorders, then appropriate treatments with antibiotics should result in improvement and even recovery. This is exactly what has been found [12-14]. The recommended treatments for mycoplasmal blood infections require long-term antibiotic therapy [15, 16], usually multiple 6-week cycles of doxycycline (200-300 mg/day), ciprofloxacin or Cipro (1,500 mg/day), azithromycin or Zithromax (500 mg/day) or clarithromycin or Biaxin (750-1,000 mg/day). Multiple cycles are required, because few patients recover after only a few cycles [12, 13], possibly because of the intracellular locations of mycoplasmas and the slow-growing nature of these microorganisms. The clinical responses that are seen are not due to placebo effects, because administration of some antibiotics, such as penicillins, resulted in patients becoming more not less symptomatic, and they are not due to immunosuppressive effects of some of the antibiotics because others that do not cause immune suppression are also effective but only if they suppress mycoplasmal infections. Some of these patients recover to a certain point and then fail to continue to respond to the recommended antibiotics, suggesting that other problems, such as viral infections, chemical exposures and other toxic events also play an important role in these illnesses, and may play a predominant role in some patients. It is thus unlikely that there exists only one explanation for chronic illnesses, such as CFS, FMS, GWI or RA. Rather, it is probably a combination of multiple toxic exposures, chemical and biological, in combination with genetic susceptibility (immune systems and/or detoxification systems) that determines whether a person succumbs to chronic illness.
Treatment recommendations for CFS/ME, FMS, GWI and RA patients with mycoplasmal infections are similar to those used to treat Lyme Disease, caused by other slow-growing intracellular bacteria that are difficult to identify and treat. Interestingly, CFS, FMS, GWI and RA patients that slowly recover after several cycles of antibiotics are generally less environmentally sensitive, suggesting that their immune systems may be returning to pre-illness states. If such patients had illnesses that were caused by psychological or psychiatric problems or by environmental or chemical exposures, they should not respond to the recommended antibiotics and recover their health. In addition, if such treatments were just reducing the autoimmune responses, then patients should not recover after the treatments are discontinued.
The treatments of chronic illnesses due to toxic exposures from chemical or radiological agents are quite different from the treatment of chronic infections . The treatment of chemically exposed patients usually involves removal of offending chemicals from the patient's environment, depletion of chemicals from the patient's system and treatment of the signs and symptoms caused by chemical exposure(s) . Chemically exposed patients are often extremely sensitive to a variety of commonly encountered chemicals, including perfumes and air freshners, petrochemical fumes, chlorine, cleaning solutions and solvents, among others. They are also very sensitive to certain foods, and special diets are often necessary, and in some cases direct skin contact with certain substances can cause strong cutaneous reactions. Therefore, an important part of treatment for chemical exposures requires limiting exposures to a variety of common chemicals and gradual removal of the toxic chemicals [17, 18].
A comprehensive approach to the therapy of chronic illnesses must be undertaken . In addition to antibiotics or removal of toxic agents, patients with CFS, FMS, GWI or RA have nutritional and vitamin deficiencies that must be corrected. For example, these patients are often depleted in vitamins B, C and E and certain minerals. Unfortunately, patients with these chronic illnesses often have poor absorption. Therefore, high doses of some vitamins must be used, and others, such as vitamin B complex, cannot be easily absorbed by the gut, so sublingual natural B-complex vitamins in small capsules or liquids should be used instead of oral capsules that are swallowed. General vitamins plus extra C, E, CoQ-10, beta-carotene, folic acid, bioflavoids and biotin are best. L- cysteine, L-tyrosine, L-carnitine and malic acid are reported by some to be useful. Certain minerals are also often depleted in GWI/CFS/FMS patients, such as zinc, magnesium, chromium and selenium.
There are also other considerations . Antibiotic use that depletes normal gut bacteria can result in over-growth of less desirable bacteria. To supplement bacteria in the gastrointestinal system yogurt and especially Lactobacillus acidophillus tablets are recommended. One product is a mixture of Lactobacillus acidophillus, Lactobacillus bifidus and FOS (fructoologosaccharides) to promote growth of these "friendly" bacteria in the gut. In addition, number of natural remedies that boost the immune system, such as whole lemon/olive extract drink or an extract of olive leaves with antioxidants are available and are potentially useful, especially during or after antibiotic therapy has been completed. Although these products appear to help some patients, their clinical effectiveness in CFS/GWI/FMS/RA patients has not been evaluated. They appear to be useful during therapy to boost the immune system or after antibiotic therapy in a maintenance program to prevent relapse of illness .
For Further Information
The Institute for Molecular Medicine can test patients for evidence of mycoplasmal infections of the types that cause human diseases like CFS, FMS, GWI and RA. Blood samples can be sent to the Institute for Molecular Medicine for mycoplasma and other testing. Since the IMM is a nonprofit institution, all testing is done at cost for a tax-deductible donation. The website for further information is: www.immed.org.
Prof. Garth L. Nicolson
The Institute for Molecular Medicine
15162 Triton Lane
Huntington Beach, CA 92649-1401
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Hypothesis on the origin of some CFS, FMS and GWI due to multiple-hits from chemical, radiological and biological sources. Chemical exposure alone can cause Multiple Chemical Sensitivity (MCS) Syndrome and Organophosphate-Induced Delayed Neurotoxicity (OPIDN), but this appears to be different from the chronic illnesses CFS, FMS, GWI, RA and others.